JAMA study says ALOS for pneumonia too long
Patients stabilize sooner than previously thought
Claiming that pneumonia patients stabilize much more quickly than previously thought, some researchers now argue that the average length of stay for patients with pneumonia is too long.
Ethan A. Halm, MD, MPH, with the department of health policy at Mount Sinai School of Medicine in New York, wrote a study on the subject as part of a far-reaching investigation by the Pneumonia Patient Outcomes Research Team (PORT) that examined 4,002 cases of hospitalized and ambulatory pneumonia patients from various medical centers. (See the study, published in the May 13, 1998, issue of the Journal of the American Medical Association.)
Detailed inpatient data were collected daily over two consecutive periods, from Oct. 15, 1991, through May 14, 1993, and from May 15, 1993, through March 31, 1994. The chart review was done on consecutive low-risk patients for the first period, and on all consecutive hospitalized patients regardless of risk for the second. This strategy resulted in what the authors call "oversampled, low-risk patients" during period one.
Including sociodemographic characteristics in their research, Halm and his colleagues looked at the initial severity of pneumonia, contributory illnesses (comorbid conditions), findings of physical examinations, laboratory results, chest X-rays, mental stability, ability to eat, and vital signs. Based on a well-established system of disease-severity classification, they grouped patients into five categories, designating Class V the sickest. In addition to lab and X-ray results, the sickest patients were defined by measurements of these vital signs:
· temperature (fever);
· heart rate (HR);
· systolic blood pressure (SBP);
· respiratory rate (RR);
· oxygenation status;
· ability to eat.
The researchers traced the stabilization of patients throughout their entire period of hospitalization. They considered a patient "stable" if all measurements in a 24-hour period met "stable criteria," which were as follows: HR of less than or equal to 100 beats/minute; SBP of more than 90 mm Hg; RR of 24 breaths/minute or less; and oxygen saturation of 90% or greater, making mechanical or supplemental oxygen supply unnecessary. Since there exists no consensus for stable temperature, the authors took "a variety of cut points" into consideration.
Studying the course of hospitalization after reaching stability, Halm considered admission to an intensive care unit (ICU), a coronary care unit (CCU), or a telemetry monitoring unit (TMU) to be a loss or reversal of stability. Researchers defined the length of hospital stay as the date of discharge minus the date of admission.
According to Halm, the results of their clinical study were clear: Assuming that a CAP patient receives an appropriate regimen, a "one-size-fits-all approach" to the length of his or her hospital stay is not warranted. The Halm study maintains that relapses in "overall stability (a significant change in at least one variable) occurred in 25% of patients according to definition A and 45% of cases for the most conservative definition E." ("Definition A" and "definition E" were used as criteria for stability, with A being the least conservative and E the most conservative.)
However, Halm maintains that "for all risk classes and definitions considered, once a patient had stabilized, the risk of clinical deterioration serious enough to merit subsequent ICU, CCU, or TMU admissions was 1% or less."
Because nearly all admissions (93%) occurred prior to a full day of stability, the researchers conclude that "it might be reasonable to define potentially unnecessary hospital days as those more than one day beyond stability." Yet, most patients studied were kept three to four days after reaching stability. The researchers concluded that this suggests that hospitalization could be shortened for the majority of CAP patients. Pointing to previous studies that indicate earlier conversion from intravenous antibiotic regimens to oral regimens as being safe, they cited that practice as further reason to eliminate longer hospital stays.
The researchers conclude their findings with the recommendation that the "use of objective criteria for stability should help providers and payers realize substantial cost savings by shortening unnecessarily long hospital stays." Halm maintains that the scientific findings of his research would benefit patients. Because the findings could serve as medical guidelines, they would save needed health care dollars and reduce the risk of secondary infections that weaken patients' resistance.
"Let's do something that's more sensible for patients and hospitals," Halm says. As a medical researcher and physician whose primary concern is the well-being of his patients, Halm maintains that unnecessarily long hospital stays are not sensible.
For more information, contact: Ethan A. Halm, MD, MPH, department of health policy, Mount Sinai School of Medicine, 5th Ave. and 100th St., New York, NY 10027.
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